COMMENT
362
T
he verdict from the International Diabetes Federation (IDF) is in: we are on the cusp of a tragedy of global proportions (IDF, 2014). Unless health professionals act decisively, a growing epidemic of diabetes, already a leading cause of death, will challenge healthcare systems throughout the world. Diabetes management comprises a complex set of activities that has to be undertaken daily, predominantly by the person with the condition. One such activity is blood-glucose testing. Based on scientific evidence, most health professionals concur that self-monitoring of blood glucose to achieve agreed normoglycaemic parameters is important to prevent potentially irreversible microvascular and macrovascular complications (The Diabetes Control and Complications Trial Research Group, 1993; UK Prospective Diabetes Study Group, 1998). For many whose diabetes is managed with insulin, and their families, the ability to measure blood glucose immediately is one of the essential management tools, enabling them to confirm suspected hypoglycaemic episodes or high glucose values rapidly and to take corrective actions. The self-monitoring of blood glucose (SMBG) becomes an integral component of self-management. Yet, the benefits of self-monitoring of blood glucose for people not using insulin, as in type 2 diabetes mellitus (T2DM) or newly diagnosed T2DM, is controversial. It is argued that hypoglycaemic events are less frequent in this group (Bodmer et al, 2008) and are confined mainly to those taking secretagogues. The degree to which individuals can adjust the dose of oral anti-diabetes drugs in response to readings is limited. A decision on whether to use SMBG in T2DM cannot be made without examining the evidence. Although hailed as one of the most important developments in diabetes care since the discovery of insulin, SMBG is considered costly for the NHS. The rising economic estimate for blood-glucose monitoring agents and devices, from £142.3 million in 2005/6 to £171.9 million in 2013/4, cannot be ignored (Health and Social Care Information Centre, 2014). It has been suggested that over half these expenditures are spent on those who do not use insulin. Should cost alone be the deciding factor to limit the use of SMBG? How robust is the evidence? In a review of 12 randomised clinical trials, Malanda et al (2013) concluded that SMBG for people with T2DM not on insulin had only a minimal, though statistically significant, impact on improving glycaemic control in the short term. Further, they found no evidence that introducing SMBG affected people’s wellbeing, quality of life, or satisfaction. These findings concur with previous reviews (such as Davidson (2010) and Farmer et al (2012)), which included many of the same studies. If SMBG at the
population level is clinically inefficacious, there is little justification for directing sparse resources to support it. It is noteworthy that many of the trials in the reviews were carried out with newly diagnosed people over a limited time period. Recent studies using SMBG as an integral component of diabetes care showed improvements in mean glucose, glycaemic variability, metabolic risk factors, depression and diabetes-related distress and health behaviours. If the goal is to ensure clinicians have the data to propose timely medication adjustments and/or lifestyle recommendations, or perhaps to alert people to necessary dietary or activity changes, SMBG may provide such data. In fact, SMBG, structured in timing and frequency, was associated with changes in clinician behaviour, with earlier and more frequent changes in the prescription of diabetes medications. It is also important to recognise that people treated with sulphonylureas are at risk of developing hypoglycaemia. The policy from the DVLA means that SMGB becomes critical for drivers for whom hypoglycaemia poses an unacceptable risk to themselves and to the public. SMBG is an invaluable tool, particularly when education empowers people to translate results from self-monitoring tests into appropriate action. Despite advances in technology, there is a paucity of robust evidence showing how education can empower people to turn self-monitoring into effective action to improve glycaemic control and the entrenched beliefs of health professionals. High-quality prospective clinical trials are required that examine the conditions that favour the best use of SMBG so that a broad, BJN indiscriminate approach can be avoided. Bodmer M, Meier C, Krahenbuhl S, et al (2008) Metformin, sulfonylureas, or other antidiabetes drugs and the risk of lactic acidosis or hypoglycemia: a nested case–control analysis. Diabetes Care 31(11): 2086–91 Davidson MB (2010) Evaluation of self monitoring of blood glucose in noninsulin-treated diabetic patients by randomized controlled trials: little bang for the buck. Rev Recent Clin Trials 5(3): 138–42 The Diabetes Control and Complications Trial Research Group (1993) The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Eng J Med 329:977-86 Farmer AJ, Perera R, Ward A, et al (2012) Meta-analysis of individual patient data in randomised trials of self monitoring of blood glucose in people with non-insulin treated type 2 diabetes. BMJ 344: e486 Health and Social Care Information Centre (2014) Prescribing for Diabetes in England: 2005-06 to 2013-14. http://tinyurl.com/ozy63x2 (accessed March 2015) International Diabetes Federation (2014) Diabetes Atlas. http://tinyurl.com/ ntfrhyk (accessed 30 March 2015) Malanda UL, Bot SD, Nijpels G (2013) Self-monitoring of blood glucose in noninsulin-using type 2 diabetic patients: it is time to face the evidence. Diabetes Care 36(1): 176–8 UK Prospective Diabetes Study Group (1998) Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and the risk of complications in patients with type 2 diabetes (UKPDS 33) Lancet 352(9131): 837-53
Danny D Meetoo Programme Leader, MSc Diabetes Care, and Lecturer, Multi-Professional Postgraduate Studies
Louise Wong Advanced Practitioner, Diabetes
© 2015 MA Healthcare Ltd
Editorial Board David Aldulaimi, Consultant Physician, Gastroenterologist, Worcestershire Acute Hospitals NHS Trust Palo Almond, Academic and Research Consultant, Anglia Ruskin University Irene Anderson, Prinicipal Lecturer and Reader in Learning and Teaching in Healthcare Practice, University of Hertfordshire Russell Ashmore, Senior Lecturer in Mental Health Nursing, Sheffield Hallam University Steve Ashurst, Critical Care Nurse Lecturer, Maelor Hospital, Wrexham Christopher Barber, Residential Nurse Dimitri Beeckman, Lecturer and Researcher, Florence Nightingale School of Nursing & Midwifery, King’s College London Lizzy Bernthal, Research Fellow and Lead Nursing Lecturer, Medical Directorate, Birmingham Martyn Bradbury, Clinical Skills Network Lead, University of Plymouth Jothi Clara J Micheal, Group Director – Nursing, Global Hospitals Group, India Emma Collins, Senior Sister, Practice Development Lead, Brighton and Sussex University Hospitals NHS Trust Alison Coull, Lecturer, Department of Nursing and Midwifery, University of Stirling, Scotland David Delaney, Charge Nurse, Clinical Research, Alder Hey Children’s Hospital Alan Glasper, Professor of Child Health Nursing, University of Southampton Angela Grainger, Assistant Director of Nursing, King’s College Hospital NHS Trust, London Michelle Grainger, Ward Manager, Moseley Hall Hospital, Birmingham Helen Holder, Senior Lecturer, Nursing Studies, Birmingham City University Mina Karamshi, Specialist Sister in Radiology, Royal Free Hospital, Hampstead Joanne McPeake, Acute Specialist Nurse/Senior Staff Nurse in Critical Care; Honourary Lecturer/Practitioner in Critical Care, University of Glasgow Danny Meetoo, Lecturer in Adult Nursing, University of Salford Mervyn Morris, Director, Centre for Mental Health Policy, Birmingham City University Aru Narayanasamy, Associate Professor, University of Nottingham Ann Norman, RCN Criminal Justice Services Nursing Adviser and Learning Disability Nursing Adviser Joy Notter, Professor, Birmingham City University & Saxion University of Applied Science, Netherlands Anne-Maria Olphert, Chief Nurse, Director of Quality, Erewash CCG, Derbyshire Hilary Paniagua, Senior Lecturer, School of Nursing & Midwifery, University of Wolverhampton Ian Peate, Director of Studies, Head of School, Gibraltar Health Authority Bernadette Porter, Nurse Consultant, National Hospital for Neurology and Neurosurgery, UCLH NHS Trust Angela Robinson-Jones, Consultant Nurse, Gynaecology, Liverpool Women’s Hospital John Tingle, HRS Reader in Health Law, Nottingham Law School, Nottingham Trent University Geoffrey Walker, Matron for Medicine, Cardiology and Specialist Nursing Services Poole Hospital NHS Foundation Trust Catherine Whitmore, Research Nurse, Diabetes and Endocrinology, University of Liverpool Jo Wilson, Director, Wilson Healthcare Services, Newcastle Cate Wood, Lecturer, Bournemouth University, PhD student at London School of Hygiene and Tropical Medicine Sue Woodward, Lecturer, Specialist and Palliative Care, Florence Nightingale Faculty of Nursing and Midwifery, King’s College London
Should blood glucose strips be used in type 2 diabetes?
British Journal of Nursing, 2015, Vol 24, No 7
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 4, 2015. For personal use only. No other uses without permission. . All rights reserved.
362
T
he verdict from the International Diabetes Federation (IDF) is in: we are on the cusp of a tragedy of global proportions (IDF, 2014). Unless health professionals act decisively, a growing epidemic of diabetes, already a leading cause of death, will challenge healthcare systems throughout the world. Diabetes management comprises a complex set of activities that has to be undertaken daily, predominantly by the person with the condition. One such activity is blood-glucose testing. Based on scientific evidence, most health professionals concur that self-monitoring of blood glucose to achieve agreed normoglycaemic parameters is important to prevent potentially irreversible microvascular and macrovascular complications (The Diabetes Control and Complications Trial Research Group, 1993; UK Prospective Diabetes Study Group, 1998). For many whose diabetes is managed with insulin, and their families, the ability to measure blood glucose immediately is one of the essential management tools, enabling them to confirm suspected hypoglycaemic episodes or high glucose values rapidly and to take corrective actions. The self-monitoring of blood glucose (SMBG) becomes an integral component of self-management. Yet, the benefits of self-monitoring of blood glucose for people not using insulin, as in type 2 diabetes mellitus (T2DM) or newly diagnosed T2DM, is controversial. It is argued that hypoglycaemic events are less frequent in this group (Bodmer et al, 2008) and are confined mainly to those taking secretagogues. The degree to which individuals can adjust the dose of oral anti-diabetes drugs in response to readings is limited. A decision on whether to use SMBG in T2DM cannot be made without examining the evidence. Although hailed as one of the most important developments in diabetes care since the discovery of insulin, SMBG is considered costly for the NHS. The rising economic estimate for blood-glucose monitoring agents and devices, from £142.3 million in 2005/6 to £171.9 million in 2013/4, cannot be ignored (Health and Social Care Information Centre, 2014). It has been suggested that over half these expenditures are spent on those who do not use insulin. Should cost alone be the deciding factor to limit the use of SMBG? How robust is the evidence? In a review of 12 randomised clinical trials, Malanda et al (2013) concluded that SMBG for people with T2DM not on insulin had only a minimal, though statistically significant, impact on improving glycaemic control in the short term. Further, they found no evidence that introducing SMBG affected people’s wellbeing, quality of life, or satisfaction. These findings concur with previous reviews (such as Davidson (2010) and Farmer et al (2012)), which included many of the same studies. If SMBG at the
population level is clinically inefficacious, there is little justification for directing sparse resources to support it. It is noteworthy that many of the trials in the reviews were carried out with newly diagnosed people over a limited time period. Recent studies using SMBG as an integral component of diabetes care showed improvements in mean glucose, glycaemic variability, metabolic risk factors, depression and diabetes-related distress and health behaviours. If the goal is to ensure clinicians have the data to propose timely medication adjustments and/or lifestyle recommendations, or perhaps to alert people to necessary dietary or activity changes, SMBG may provide such data. In fact, SMBG, structured in timing and frequency, was associated with changes in clinician behaviour, with earlier and more frequent changes in the prescription of diabetes medications. It is also important to recognise that people treated with sulphonylureas are at risk of developing hypoglycaemia. The policy from the DVLA means that SMGB becomes critical for drivers for whom hypoglycaemia poses an unacceptable risk to themselves and to the public. SMBG is an invaluable tool, particularly when education empowers people to translate results from self-monitoring tests into appropriate action. Despite advances in technology, there is a paucity of robust evidence showing how education can empower people to turn self-monitoring into effective action to improve glycaemic control and the entrenched beliefs of health professionals. High-quality prospective clinical trials are required that examine the conditions that favour the best use of SMBG so that a broad, BJN indiscriminate approach can be avoided. Bodmer M, Meier C, Krahenbuhl S, et al (2008) Metformin, sulfonylureas, or other antidiabetes drugs and the risk of lactic acidosis or hypoglycemia: a nested case–control analysis. Diabetes Care 31(11): 2086–91 Davidson MB (2010) Evaluation of self monitoring of blood glucose in noninsulin-treated diabetic patients by randomized controlled trials: little bang for the buck. Rev Recent Clin Trials 5(3): 138–42 The Diabetes Control and Complications Trial Research Group (1993) The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Eng J Med 329:977-86 Farmer AJ, Perera R, Ward A, et al (2012) Meta-analysis of individual patient data in randomised trials of self monitoring of blood glucose in people with non-insulin treated type 2 diabetes. BMJ 344: e486 Health and Social Care Information Centre (2014) Prescribing for Diabetes in England: 2005-06 to 2013-14. http://tinyurl.com/ozy63x2 (accessed March 2015) International Diabetes Federation (2014) Diabetes Atlas. http://tinyurl.com/ ntfrhyk (accessed 30 March 2015) Malanda UL, Bot SD, Nijpels G (2013) Self-monitoring of blood glucose in noninsulin-using type 2 diabetic patients: it is time to face the evidence. Diabetes Care 36(1): 176–8 UK Prospective Diabetes Study Group (1998) Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and the risk of complications in patients with type 2 diabetes (UKPDS 33) Lancet 352(9131): 837-53
Danny D Meetoo Programme Leader, MSc Diabetes Care, and Lecturer, Multi-Professional Postgraduate Studies
Louise Wong Advanced Practitioner, Diabetes
© 2015 MA Healthcare Ltd
Editorial Board David Aldulaimi, Consultant Physician, Gastroenterologist, Worcestershire Acute Hospitals NHS Trust Palo Almond, Academic and Research Consultant, Anglia Ruskin University Irene Anderson, Prinicipal Lecturer and Reader in Learning and Teaching in Healthcare Practice, University of Hertfordshire Russell Ashmore, Senior Lecturer in Mental Health Nursing, Sheffield Hallam University Steve Ashurst, Critical Care Nurse Lecturer, Maelor Hospital, Wrexham Christopher Barber, Residential Nurse Dimitri Beeckman, Lecturer and Researcher, Florence Nightingale School of Nursing & Midwifery, King’s College London Lizzy Bernthal, Research Fellow and Lead Nursing Lecturer, Medical Directorate, Birmingham Martyn Bradbury, Clinical Skills Network Lead, University of Plymouth Jothi Clara J Micheal, Group Director – Nursing, Global Hospitals Group, India Emma Collins, Senior Sister, Practice Development Lead, Brighton and Sussex University Hospitals NHS Trust Alison Coull, Lecturer, Department of Nursing and Midwifery, University of Stirling, Scotland David Delaney, Charge Nurse, Clinical Research, Alder Hey Children’s Hospital Alan Glasper, Professor of Child Health Nursing, University of Southampton Angela Grainger, Assistant Director of Nursing, King’s College Hospital NHS Trust, London Michelle Grainger, Ward Manager, Moseley Hall Hospital, Birmingham Helen Holder, Senior Lecturer, Nursing Studies, Birmingham City University Mina Karamshi, Specialist Sister in Radiology, Royal Free Hospital, Hampstead Joanne McPeake, Acute Specialist Nurse/Senior Staff Nurse in Critical Care; Honourary Lecturer/Practitioner in Critical Care, University of Glasgow Danny Meetoo, Lecturer in Adult Nursing, University of Salford Mervyn Morris, Director, Centre for Mental Health Policy, Birmingham City University Aru Narayanasamy, Associate Professor, University of Nottingham Ann Norman, RCN Criminal Justice Services Nursing Adviser and Learning Disability Nursing Adviser Joy Notter, Professor, Birmingham City University & Saxion University of Applied Science, Netherlands Anne-Maria Olphert, Chief Nurse, Director of Quality, Erewash CCG, Derbyshire Hilary Paniagua, Senior Lecturer, School of Nursing & Midwifery, University of Wolverhampton Ian Peate, Director of Studies, Head of School, Gibraltar Health Authority Bernadette Porter, Nurse Consultant, National Hospital for Neurology and Neurosurgery, UCLH NHS Trust Angela Robinson-Jones, Consultant Nurse, Gynaecology, Liverpool Women’s Hospital John Tingle, HRS Reader in Health Law, Nottingham Law School, Nottingham Trent University Geoffrey Walker, Matron for Medicine, Cardiology and Specialist Nursing Services Poole Hospital NHS Foundation Trust Catherine Whitmore, Research Nurse, Diabetes and Endocrinology, University of Liverpool Jo Wilson, Director, Wilson Healthcare Services, Newcastle Cate Wood, Lecturer, Bournemouth University, PhD student at London School of Hygiene and Tropical Medicine Sue Woodward, Lecturer, Specialist and Palliative Care, Florence Nightingale Faculty of Nursing and Midwifery, King’s College London
Should blood glucose strips be used in type 2 diabetes?
British Journal of Nursing, 2015, Vol 24, No 7
British Journal of Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 4, 2015. For personal use only. No other uses without permission. . All rights reserved.
